Tuberculosis is a highly contagious infectious disease that is one of the world’s deadliest. Globally, about 10 million people developed the disease, and 98% of the world’s registered TB cases were in low-and middle-income countries (LMICs) (1). In Nepal, around 40% of Nepalese participants in the End TB program did not seek TB care and treatment, according to Nepal’s 2018 national TB prevalence survey (2). Approximately 15 people die by tuberculosis, and over 180 people become ill with this preventable and curable disease in Nepal (2).

Tuberculosis control program was systematically started about 6 decades ago and there was a triple agreement between Government of Nepal, World Health Organization and UNICEF (3). Since that time, there has been historic progress toward the tuberculosis control program in Nepal. Primary health care to UN sustainable development goal, tuberculosis control is one of the important target and quality service is still challenge in Nepal (4, 5). Only state approach is not sufficient and utilization of private sector and community participation is essential to control TB control program (6). The Public-Private Mix (PPM) approach is a strategic initiative with the goal of enlisting all private and public health care providers in the fight against tuberculosis while adhering to international health care standards. It is a globally effective intervention strategy. Public-Private Mix has played a significant role in tuberculosis control, significantly contributing to case detection, diagnosis, and treatment (7). A public-private mix (PPM) model for directly observed therapy short course (DOTS), involving a partnership between the government and the private health sector, plays a critical role in accelerating progress in TB control. Private sector contributed 19, 18 and 23 percent for the diagnosis and treatment of TB cases in 2015, 2016 and 2017, respectively, in Nepal (6). An ongoing challenge is identifying hidden cases and ensuring that identified tuberculosis patients complete treatment according to protocol. When the PPM approach is not implemented, a presumptive TB patient visits a private service provider that is not affiliated with the National Tuberculosis Programme (NTP) and undergoes a slew of unnecessary diagnostic tests before receiving the correct diagnosis and anti-TB treatment. When the PPM approach is implemented, the patient receives a free sputum microscopy test and, if diagnosed with TB, is given free anti-TB drugs.

Previous studies mostly focus on prevalence (8), multiple factors associated with diagnosis, treatment status (9, 10), health seeking behaviors (11), knowledge and awareness level regarding tuberculosis in Nepal. Studies identified various barriers such as public sector factors, private sector system factors, program implementation factors, and policy for private public mixed method (12, 13). TB burden and case notification rates in Nepal vary across provinces and nations over time. It is critical to identify actual barriers in the context of Nepal. Approximately 69,000 people diagnosed with tuberculosis (TB) in 2018, but the incidence was 1.6 times higher; approximately 117,000 people are living with TB, and 30,000 cases were missed to detect (2).

Presumptive TB patients are more likely to visit private hospitals for identification and diagnosis of TB, but the majority of private hospitals do not report cases to government health systems. If cases diagnosed in private hospitals were notified and enrolled in the government health system, the target cases for the national tuberculosis control program could be met to some extent (14). There is still challenge to find out the new case in rural, urban slums area and HIV co infection in tuberculosis control program and appropriate utilization of private sector with community participation would be the opportunity (6). The study’s goal was to identify the barriers to implementing the private-public mix approach to finding tuberculosis cases, which would be useful for policymakers and program managers planning to implement the PPM approach. Based upon these insights, collaboration should be done with the private sector, and jointly supportive monitoring and supervision to identify gaps in the private sector would help in case finding. Effective training and orientation programs for all practitioners, including those in the private sector, will help the tuberculosis program, the recording and reporting system, and treatment outcomes.

There are 33 HFs in Kaski District that are linked in a private-public mixed approach to increase TB case notification and reduce missing TB cases in the Gandaki Province.

This is qualitative study to explore the barriers in PPM in TB control program particularly case findings, case holding and preventive measures so that TB case could complete the treatment according to treatment protocol. On the other hand, PPM would contribute to minimize the complications and transmission to another person. The major theme was categorized under case detection, patients’ behaviors and health system barriers. Private health sectors who involved in TB control program were interested to their profit where government organization/personnels with office time and need to motivate with social responsibility because TB transmission affects every sector of community and state.

Our study discovered that private practitioners spend a small amount of time in polyclinics and private hospitals; they usually visit clinics “on call”; additionally, there are a limited number of staff and the need to multitask, which is similar to Lucie Blok’s study (17) which discovered that health workers and managers complained about critical staff shortages, resulting in multitasking and a perception of workload in the workplace (18). Das and Baidya (19) as well as (20) highlights poor knowledge of TB among the tuberculosis patients. Another study of Samal (21) highlights contrast finding which showed good knowledge of TB patients on TB.

Identifying barriers to TB treatment at community health centers revealed that a lack of healthcare providers also had an impact on TB treatment care (22). Individual training will be more difficult to provide when new staff members lack TB management experience (23). The frequent turnover of paramedics and laboratory technicians has been cited as a major source of concern in using private hospitals (12). Because of differences in diagnosis and treatment criteria, there was ineffective external coordination with private healthcare facilities. Coordination with TB stakeholders was difficult in managing TB cases according to national guidelines (23). Another study identified poor recognition of the private sector, in addition to training and orientation, as a barrier to PPM (12). Not all private health care centers have the necessary equipment to diagnose tuberculosis. This can result in incorrect TB diagnosis and treatment. As a result, failures of private centers to refer or report TB patients to government centers have been identified as case-finding and reporting issues (23). Patient confidentiality was cited as the top reasons for not referring patients to RNTCP (12). A study identified five barriers in the TB treatment and monitoring activities: delayed treatment, different TB regimens, inadequate drug monitoring, non-adherence to medication, and difficulties in managing adverse drug reactions (23, 24). Given that public health facilities have significant responsibilities in healthcare, collaboration with private facilities through the PPM program is strongly encouraged. Nonetheless, a study found that PPM at the government health center faced several challenges, including a lack of private sector interest, a lack of exposure to the DOT strategy in the private sector, and insufficient local regulation to engage private sectors. Human resource shortages and external coordination, as described in organizational capacity, impacted the performance of the PPM program at the community level (23). Study of India and Kerala found no good involvement of private sectors toward NTP. Some of the factors identified for poor private sector engagement included: a lack of initiative on the part of the government, a negative attitude among government employees toward the private sector, and power imbalances between government employees and service providers at private clinics/hospitals (12). Another reason given by private sectors for not referring patients to the government system is fear of losing them (12). As a result, private hospitals regard public health as a low priority issue. The private sector is preoccupied with patients and business (12).

Pradipta et al. discovered stigmatization of TB patients in the community, in which the patients felt the community disapproved of them and feared close contact with them (25). For any public-private mix model to work, the government must fulfill its stewardship role with sincerity and responsibility. This allows the partners to develop trust. According to the findings of the study, any flaws in the partners’ liaison lead to numerous misunderstandings. Finally, it is critical to ensure that the patients, who are the primary beneficiaries of this collaboration, are not marginalized (26).

The study concludes that numerous barriers exist in the way of effective implementation of the PPM approach, including TB case detection barriers such as knowledge of TB diagnosis and treatment, HW attitude, workload, patient-related barriers such as knowledge of TB, self-medication practice, stigma and discrimination, financial status, and health system-related barriers such as staff turnover and poor engagement of the private sector in workshops, trainings, recording, and re-evaluation. Government stakeholders must work together with private sector stakeholders to perform joint monitoring and supervision. Private practitioners should receive training and orientation, and presumptive TB patients should be given adequate time and counseling as well as motivation to visit a government health facility.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethical approval was taken from the Institutional Review Committee of Pokhara University Research Centre (PU-IRC 43/077/078). Written informed consent was obtained from the participants for the publication of any potentially identifiable images or data included in this article. The research was explained to respondents and verbal consent was taken from all respondents prior to conducting the interview. Participants were informed that confidentiality would be maintained during the research. They were also made aware that their participation was voluntary and could withdraw their participation at any point without any consequences.

SB, RY, DY, and NS: conceptualization. SB, RY, RM, AN, PS, and SrP: data curation. SB, KS, SoP, YB, and RY: formal analysis. KK, LB, and ST: investigation. DY, SB, RY, SM, RM, and PS: methodology. SB, SrP, NS, KK, and AN: supervision. ST, SB, SM, and RY: validation. ST, SM, KK, and DY: visualization. SB, RY, SrP, LB, and AN: writing – original draft. SB, CR, RY, DY, KK, ST, NS, and RM: writing – review and editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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